Provider Demographics
NPI:1013479427
Name:GREEN, KYLE MARCUS (MD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:MARCUS
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 THIRD AVE STE A
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-1352
Mailing Address - Country:US
Mailing Address - Phone:619-425-7755
Mailing Address - Fax:
Practice Address - Street 1:835 THIRD AVE STE A
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-1352
Practice Address - Country:US
Practice Address - Phone:619-425-7755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2025-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA201155207WX0107X
IAMD-51262207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist